A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
“I need to make sure that the potential victim is warned."
"I need to keep the information confidential due to the client's right to privacy."
“I can only discuss the client's threats with a court order."
"I should verbally report this information to the psychiatrist."
The Correct Answer is A
A. "I need to make sure that the potential victim is warned."
Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.
B. "I need to keep the information confidential due to the client's right to privacy."
Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.
C. "I can only discuss the client's threats with a court order."
Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.
D. "I should verbally report this information to the psychiatrist."
Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.
B) "This medication is addictive, so you will need to discontinue it in six months."
Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.
C) "Weight gain should be reported to your provider as an indication of lithium toxicity."
While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.
D) "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."
Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.
Correct Answer is ["2"]
Explanation
The nurse is preparing to administer benztropine 2 mg IM every 12 hours. The concentration of the available benztropine is 1 mg/mL.
To calculate the volume (mL) of the medication needed for the prescribed dose, you can use the formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = 2 mg / 1 mg/mL = 2 mL
So, the nurse should administer 2 mL of benztropine 1 mg/mL for each dose. Since we're looking for a whole number, we round to the nearest whole number, which is 2 mL.
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